Staff Child Report

O MB No.: 0970–0354

Expiration Date: xx/xx/xxxx

AFFIX LABEL HERE

Staff Child Report – Home Visitors

Draft for OMB (Redacted)

This cross-walk version of the questionnaire includes items to be asked of home visitors working with pregnant women and families with children ages newborn to 36 months, flagged as appropriate for the relevant age forms:

• Version 0 (V0): Pregnant women

• Version 1 (V1): Newborn to 7 month

• Version 2 (V2): 8 months to 16 months

• Version 3 (V3): 17 months to 30 months

• Version 4 (V4): 31 months to 37 months

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number for this information collection is 0970–0354 and the expiration date is XX/XX/XXXX.

ABOUT THIS SURVEY

• The questions in this survey are about the Baby FACES [client/child’s family] listed on the cover page of this form. This collection of information will be used to describe the characteristics of children and families served by Early Head Start, and the characteristics and features of programs and staff that serve them.

• Throughout this survey, we will be asking you to respond to questions about your interactions with this [client/child’s parent]. [This can include the child’s mother or a guardian who serves as the child’s primary caregiver. When responding to these questions, please think about the parent who you interact with most often, unless otherwise noted.]

• The survey will take about 15 minutes to complete. The questions in this survey can be answered by marking an “X” in the box. For a few questions, you will be asked to write in a brief response.

1 □ 2 □ 3 □

• If you are unsure how to answer a question, please give the best answer you can rather than leaving it blank.

• Your participation in the study is voluntary. All information you provide will be kept private to the extent permitted by law. Neither your name nor the [child’s or] family’s name will be attached to any information you give us; and it will not be shared with others at your Early Head Start program.

• If you have any questions, please contact the Baby FACES team at Mathematica Policy Research at [toll-free number].

Source: Items A1-A4 adapted from Baby FACES 2009

Included in versions: 0 [pregnant women], 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions

A1. Are you currently the Early Head Start home visitor for the [client/child’s family] listed on the cover page of this form?

1 □ Yes

0 □ No

A1a. For how many months have you been providing home visit services to this [client/family]?

|___|___| MONTHS [V0: D6 / V1: GO TO D1 / V2: GO TO A5 / V3-V4: GO TO B1]

A2. What is the main reason you are no longer this [client’s/family’s] home visitor?

MARK ONE ONLY

1 □ [Client/Family] transferred to another home visitor in the same [program/center]

2 □ Child moved from home- to center-based care in this program [N/A for version 0]

3 □ Child moved to another center in this program [N/A for version 0]

4 □ [Client/Family] left this Early Head Start program

A3. What is the name of this [client’s/child’s] current Early Head Start home visitor [or teacher]?

Name:

You have reached the end of this survey.

Please return this form to the Mathematica staff person when he/she visits your center.

A4. Please record the last date you had this [client/family] on your caseload.

| | | / | | | / | | | | |

month day year

ONLY FOR VERSION OF INSTRUMENT FOR HV’S OF CHILDREN 8-16 MONTHS OLD. FOR THIS AGE FORM, HV’S OF CHILDREN 8 TO 11 MONTHS WILL BE ROUTED OUT OF THE BITSEA.

Source: New item

A5. Is this child 12 months of age or older?

1 □ Yes

0 □ No GO TO C1 (PAGE XX)

Source: BITSEA, B1-B2 (PROPRIETARY)

Included in versions: 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]

Same items for all age versions (appropriate for 12-36 months only)

B1. The first set of questions contains statements about 1- to 3-year-old children. Many statements describe normal feelings and behaviors, but some describe things that can be problems. Some may seem too young or too old for this child. Please do your best to answer every question.

For each statement, please mark the answer that best describes this child in the past month.

Items B1a to B1hh are protected under copyright and have been redacted from this instrument.

Source: Briggs-Gowan, M.J., and A.S. Carter. The Brief Infant–Toddler Social and Emotional Assessment (BITSEA). San Antonio, TX: Harcourt Assessment, 2006.

B2. The following questions are about feelings and behaviors that can be problems for young children. Some of the questions may be a bit hard to understand, especially if you have not seen them in a child. Please do your best to answer them anyway.

For each statement, please mark the answer that best describes this child in the past month.

Items B2a to B2h are protected under copyright and have been redacted from this instrument.

Source: Briggs-Gowan, M.J., and A.S. Carter. The Brief Infant–Toddler Social and Emotional Assessment (BITSEA). San Antonio, TX: Harcourt Assessment, 2006.

HOME VISITORS WILL BE ASKED TO COMPLETE THE ENGLISH CDI WORD LIST USING THE RELEVANT AGE FORM: LEVEL I (8-18 MONTHS); LEVEL II (16-30 MONTHS); OR LEVEL III (30-37 MONTHS). THESE AGE-BASED VOCABULARY LISTS INCLUDE APPROXIMATELY 100 WORDS EACH AND ARE APPENDED AT THE END OF THIS DOCUMENT.

Source: MacArthur-Bates Communicative Development Inventories, Infant and Toddler Short Forms and CDI-III (PROPRIETARY)

Included in versions: 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; Different item sets for age versions

C1. The following is a list of typical words in young children’s vocabularies. We are interested specifically in the words this child understands or say in English.

For words this child does not yet understand, mark the first column (does not understand). For words he/she understands but does not yet say, mark the second column (understands). For words he/she understands and also says, mark the third column (understands and says). If this child uses a different pronunciation of a word (for example, “raffe” for “giraffe” or “sketti” for “spaghetti”) mark the word anyway. For each item, mark only one response.

Remember, this is a “catalogue” of words that are used by many different children. Don’t worry if this child knows only a few right now.

These items are protected under copyright and have been redacted from this instrument.

Source: MacArthur-Bates Communicative Development Inventories.

Source: MacArthur-Bates Communicative Development Inventories, Infant Long Form, First Communicative Gestures (12 items) (PROPRIETARY)

Included in versions: 2 [8-16 mos]

C2.1. When infants are first learning to communicate, they often use gestures to make their wishes known. For each item below, mark the response that describes this child’s actions right now.

Items C2.1a to C2.1l are protected under copyright and have been redacted from this instrument.

Source: MacArthur-Bates Communicative Development Inventories.

Source: MacArthur-Bates Communicative Development Inventories, Toddler Short Form and CDI-III, Combining words (PROPRIETARY)

Included in versions: 3 [17-30 mos] and 4 [31-37 mos]

C2.2. This item is protected under copyright and has been redacted from this instrument.

Source: MacArthur-Bates Communicative Development Inventories

Source: MacArthur-Bates Communicative Development Inventories, Sentences, CDI-III (PROPRIETARY)

Included in versions: 4 [31-37 mos]

C2.3. For each pair of sentences below, mark the one that sounds most like the way this child talks at the moment. If this child is saying sentences even more complicated than the two provided, mark the second one.

Items C2.3a to C2.3l are protected under copyright and have been redacted from this instrument.

Source: MacArthur-Bates Communicative Development Inventories.

Source: MacArthur-Bates Communicative Development Inventories, Using Language, CDI-III (PROPRIETARY)

Included in versions: 4 [31-37 mos]

C2.4. These next questions are about how this child uses language to communicate in English. For each item, mark only one response.

Items C2.4a to C2.4l are protected under copyright and have been redacted from this instrument.

Source: MacArthur-Bates Communicative Development Inventories.

D1. Since September, has this child been given a developmental screening? 1  Yes 0  No GO TO D6 D2. What screening tool or tools did you use to assess this child? mark all that apply 1  Ages and Stages Questionnaire (ASQ) 2  Brigance Screens 3  Creative Curriculum Tools 4  Denver Developmental Screening Test 5  Devereux Early Childhood Assessment (DECA) 6  Early Learning Accomplishment Profile 7  The Ounce Scale 8  Agency-created screener 9  Some other screening tool (Please specify) D3. Did the child’s score on the developmental screening tool cause you to be concerned about the child’s development? 1  Yes 0  No GO TO D6 D4. Since September, has this child ever been referred to Part C (or Part B) for a developmental concern? 1  Yes 0  No GO TO D6

D5. What was the reason for the referral? mark all that apply 1  Behavior problem 2  Emotional problem 3  Attention problem 4  Developmental or cognitive delay 5  Problems with the use of arms or legs 6  Speech problem 7  Hearing problem 8  Vision problem 9  Something else (Please specify) D6. Thinking about [the entire family/this child and the child’s entire family], have you referred anyone in the family to any of the following since September? mark all that apply 1  Health care provider 2  Prenatal care provider 3  Mental health care provider 4  Disabilities services provider 5  Child care partner or other child care provider 6  Other community service provider (such as job training, housing assistance provider) 7  None of the above

SECTION D. CHILD DEVELOPMENT

Source: Items D1 to D6 adapted from Baby FACES 2009

Included in versions: 0 [pregnant women] (D6 only), 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for versions 1-4

Source: Items E1-E6, E8-E9 adapted from MIHOPE Family Services Home Visitor Log

Included in versions: 0 [pregnant women], 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions

In this section, we want you to think about the contact you have had with this family during the past 4 weeks, specifically face-to-face and non-face-to-face contacts. You will also be asked to think back to any visits you had scheduled for the past 4 weeks that did not occur. Please answer the following questions to your best ability and only with regard to this particular family.

E1. Did you have any contact with this family during the past 4 weeks?

1 □ Yes

0 □ No GO TO E2

E2. What was the main reason for there being no contact with this family during the past 4 weeks?

MARK ONE ONLY

1 □ No scheduled contact

2 □ Scheduled in-person visit did not occur

GO TO F1

(PAGE XX)

3 □ Unable to locate

4 □ Excessive missed appointments

5 □ [Client lost custody]

6 □ Client declined further participation (this would include going back to work, school, getting services from other agencies, pressure from family members, etc.)

7 □ Other (specify)

E3. Excluding any group activities, how many face-to-face (in-person) visits did you have with this family during the past 4 weeks?

MARK ONE ONLY

1 □ 0 GO TO E9 (PAGE XX)

2 □ 1

3 □ 2

4 □ 3

5 □ 4

6 □ More than 4

E4. During any of the face-to-face contacts you had with this family during the past 4 weeks, which of the following topics/activities were addressed?

MARK ALL THAT APPLY

CAREGIVER

1 □ Domestic violence or anger management

2 □ Education

3 □ Economic management/financial self-sufficiency

4 □ Family planning

5 □ Finding alternate caregivers/child care

6 □ Housing

7 □ Job training and employment

8 □ Maternal physical health (outside of pregnancy)

9 □ Mental health or stress

10 □ Prenatal health behaviors/prenatal care

11 □ Social support

12 □ Tobacco use

13 □ Alcohol use

14 □ Other drug use

PARENTING BEHAVIOR/CHILD OUTCOMES

15 □ Breastfeeding/feeding/nutrition

16 □ Child development

17 □ Child health

18 □ Child/home safety

19 □ Co-parenting

20 □ Developmentally appropriate care/routines

21 □ Discipline/behavior management

22 □ Lead exposure in home

23 □ Parent-child interaction

FAMILY

24 □ Health insurance/Medicaid/SCHIP

25 □ Public/governmental assistance

E5. In the past 4 weeks, did you refer this family to services or provide agency contact information for any of the following areas?

MARK ALL THAT APPLY

1 □ Adult education services (including GED and ESL)

2 □ Childcare

3 □ Domestic violence counseling/anger management

4 □ Domestic violence shelter

5 □ Early intervention services/Part C services

6 □ Family planning and reproductive health care

7 □ Housing

8 □ Job training and employment

9 □ Maternal preventive care

10 □ Mental health treatment

11 □ Pediatric primary care

12 □ Prenatal care

13 □ Public assistance (SNAP, WIC, Medicaid, SCHIP, TANF, etc.)

14 □ Alcohol abuse treatment

15 □ Drug abuse treatment

16 □ Resources to help quit or reduce smoking or vaping

0 □ did not provide referrals or provide agency contact information during the past 4 weeks

For these next questions, please think about the most recent home visit you had with this family during the past 4 weeks.

E6. Who participated in the home visit?

MARK ALL THAT APPLY

1 □ Mother of child/pregnant client

2 □ [Focal child]

3 □ Father of child/client’s current partner

4 □ Other adult family member

5 □ Other child(ren) in the home

6 □ Other professional (nurse, early interventionist, child welfare worker, supervisor, etc.)

Source: Adapted from Baby FACES 2009 Content and Characteristics Form

E7. How well aligned were the activities and topics you had planned to cover during your most recent home visit compared with what actually happened? A value of “1” indicates that the visit was “not well aligned” with what you had planned, and a value of “5” means it was “very well aligned.”

SELECT ONE RESPONSE
NOT WELL ALIGNED					VERY WELL ALIGNED
1 □	2 □		3 □	4 □		5 □ GO TO E8

GO TO E7a

Source: Adapted from Baby FACES 2009 Content and Characteristics Form

E7a. Please mark the reason(s) why you feel your most recent visit with this family was not very well aligned with what you planned to accomplish.

MARK ALL THAT APPLY

1 □ Family crisis

2 □ Sick client or child

3 □ Client [or child] not engaged in activity

4 □ Space constraints

5 □ Client interested in another topic

6 □ Presence of other people limited client’s responses

7 □ Other (specify)

E8. How would you describe the family follow through from the previous visit?

MARK ONE ONLY

0 □ not applicable – no follow through anticipated/assigned

1 □ Client could not remember previous activities/discussion/referrals

2 □ Client remembered but did not follow through

3 □ Client followed through incompletely

4 □ Client followed through completely

E9. Excluding any group activities, how many face-to-face (in-person) visits were scheduled with this family during the past 4 weeks?

MARK ONE ONLY

1 □ 0 GO TO E11 (PAGE XX)

2 □ 1

3 □ 2

4 □ 3

5 □ 4

6 □ More than 4

Source: New item

E10. Which of the following are reasons for why one or more visits that were scheduled in the past 4 weeks did not take place?

MARK ALL THAT APPLY

0 □ all scheduled visits in past 4 weeks took place

1 □ You needed to cancel the visit or reschedule the appointment

2 □ The [client/family] cancelled, was not home, or did not come to the visit

Source: New item

E11. During the past 4 weeks, in which of the following ways have you communicated with this family?

	MARK ONE PER ROW
	Did you communicate in this way in the past 4 weeks?
	YES		NO
a. Talking or leaving messages via telephone	1 		2 
b. Texting	1 		2 
c. Sending emails	1 		2 
d. Writing notes or letters	1 		2 
e. Connecting via social networking sites	1 		2 
f. Other (specify)	1 		2 
_____________________________________

Source: New item

E11a. Thinking about a typical week (during the past 4 weeks), how often did you communicate with this family in any of these ways?

MARK ONE ONLY

0 □ 0

1 □ 1

2 □ 2

3 □ 3

4 □ 4

5 □ More than 4

Source: Working Alliance Inventory (adapted for used in EBHV) (PROPRIETARY)

Included in versions: 0 [pregnant women], 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions

F1. Below are statements that describe ways a home visitor might think or feel about the [client/parent] with whom she/he is working. For each statement, please check the box that describes how often you think or feel that way. For example, if the statement describes the way you always think or feel, mark “always.” Work fast, your first thoughts are the ones we would like to see. Please don't forget to respond to every item.

Items F1a to F1l are protected under copyright and have been redacted from this instrument.

Source: Working Alliance Inventory (adapted for used in EBHV)

Source: Home-School Relationship Measure from NCEDL Teacher-Student Report (PROPRIETARY)

Included in versions: 0 [pregnant women], 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions

F2. Please tell us which option best describes your relationship with this [client/child’s parent].

Items F2a to F2g are protected under copyright and have been redacted from this instrument.

Source: Home-School Relationship Measure, NCEDL Teacher-Student Report.

Source: Items G1-G2 adapted from Baby FACES 2009

Included in versions: 0 [pregnant women G2 only], 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions

G1. In which, if any, of the following ways has this family participated in Early Head Start since September? If both parents are involved, please answer the questions concerning both parents.

	MARK ONE PER ROW
	Has this parent/family participated?
ITEMS B AND C NOT IN THIS VERSION	NO	YES
a. As members of a parent council or other governing bodies?	0 	1 
d. By helping at special events or activities?	0 	1 
e. By attending special events or activities, such as a children's performance, or a holiday party?	0 	1 
f. By attending parent workshops?	0 	1 

G2. For each of the following, please mark the response that best describes how engaged this [client/parent] has been in the program since September.

a. Thinking first about appointments, would you say…

1 □ [Client/Parent] kept most appointments scheduled since September

2 □ [Client/Parent] kept some appointments, but cancelled others

3 □ [Client/Parent] missed or cancelled most appointments

4 □ [Client/Parent] had no scheduled appointments since September

ITEM B NOT IN THIS VERSION

c. Now thinking about this [client’s/parent’s] participation in activities offered by the program, would you say…

1 □ [Client/Parent] participated in many activities offered by the program since September

2 □ [Client/Parent] participated in some activities, but passed on many others

3 □ [Client/Parent] participated in only a few activities offered by the program

4 □ [Client/Parent] did not participate in any activities since September

d. Which best describes this [client’s/parent’s] attitude and receptivity to the program? Would you say…

1 □ [Client/Parent seemed very engaged, asked questions, was willing to try new things

2 □ [Client/Parent was somewhat engaged, asked a few questions, was hesitant to try a few new things

3 □ [Client/Parent was not engaged, didn’t ask many questions, little interest in new things

e. How would you describe the family’s participation in group socialization activities? Would you say…

1 □ They have attended all or nearly all the offered group socialization activities since September

2 □ They have attended some of the group socialization activities

3 □ They have attended at least one group socialization activity

4 □ They have not attended any group socialization activities since September

G3. Please indicate today’s date:

| | | / | | | / | | | | |

month day year

Please return this questionnaire to the Mathematica staff person when he/she visits your center.

Thank you for your participation in Baby FACES!